Claim for Damages
Name of Claimant
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of when Injury or Damage occurred
-
Month
-
Day
Year
Date
Time of day of when the Injury or Damage occurred
Location/Address of where Damage or Injury occurred
How did the Damage or Injury Occur? Please describe in detail
Name(s) of employee(s) involved
What Action or Inaction of the City Employee(s) caused the damage or injury
What damage or Injury did you suffer
Total Amount of Claim
If the claim totals less than $10,000.00 as of the date of the presentation of this claim, please attach any bills for medical treatment and expenses and two estimates or bills for personal damaged property. If the claim amount exceeds $10,000.00, no dollar amount shall be included. However, please indicate whether jurisdiction over the claim would rest in municipal or superior court. Completing this form does not guarantee the acceptance of damages by the City of Soledad. All claims are subject to consideration by the City Council, and the City Attorney will notify the claimant in writing after the City Council has considered them
SIGN AND DATE THIS CLAIM FORM. IF THE SIGNER IS NOT THE CLAIMANT, INDICATE THE RELATIONSHIP OF THE SIGNER TO THE CLAIMANT. (Parent, Attorney, Etc.)
Date
-
Month
-
Day
Year
Date
Indicate the relationship of the signer to the claimant if the signer is NOT the claimant.
PRESENTATION OF A FALSE CLAIM IS A FELONY
Submit
Submit
Should be Empty: